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3 ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE.USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �leJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT . <br /> t <br /> Owner's Name �• Phone 30 <br /> Address ti," ��y` City <br /> - i <br /> Contractor's Name License Phone <br /> - <br /> TYPE OF WORK (Check) : NEW;WELL /�EEPEN / / RECONDITION / /�D STRUCTI0N)-'�/-7 2� <br /> PUMP INSTALLATION / UMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK WER LINES PIT PRIVY 1 <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE .. TYPE OF WELL CONSTRUCTION SPECIFICATIONS X1 <br /> Industrial ` = :! Cable Tool Dia. of Well Excavation '� Q <br /> Domestic/private t Drilled 3 Dia. of Well Casing <br /> D mestic/publics _: Driven ;-- Gauge -of 4Casln-g <br /> rigation 4 Gravel Pack Depth of Grout Seal �1 <br /> Cathodic Protection :. V-- r '_Rotary t Type of Grout <br /> .Disposal. Other i Other Information ' '. ., <br /> Geophysical ' Surface Seal Installed By: ` <br /> f <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump �^.rt• ... .� »�.� H.P. - <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done k" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I` I hereby agree to comply with all laws and 'ragula'ti(ri's-•of-the�San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work-on a new well, I will furnish the `San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of ,the%well and notify them before putting the .well in use.. The above <br /> information is true to the best of my knowledge and belief. I- WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEUTION. <br /> SIGNED TITLEct <br /> (DRAW-PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATED <br /> APPLICATION ACCEPTED BY �T— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYPECTrON BY 4,,r" DATE�►� <br /> F H IL26 Rau_ 1-.71, . <br />